CBT and Bulimia CBT and Bulimia NervosaNervosa

Tara WeatherillTara Weatherill

The Cognitive Model of BNThe Cognitive Model of BN(Fairburn, 1993)(Fairburn, 1993)

o Five Core Domains Five Core Domains Involved in Involved in Maintenance:Maintenance:

1.1. Negative self Negative self evaluation.evaluation.

2.2. Extreme body image Extreme body image concernconcern

3.3. Dietary constraint Dietary constraint

4.4. Binge Eating Binge Eating

5.5. Compensatory Compensatory Behaviour (Purging)Behaviour (Purging)

The Cognitive Model of BN-The Cognitive Model of BN-Revised (Fairburn, 2003)Revised (Fairburn, 2003)

o Not used to replace old model (given all the evidence to support it)

o Just used as supplement

oAdditional maintaining mechanisms:

1.clinical perfectionism

2.mood intolerance

3.interpersonal difficulties

How does it Work?How does it Work?

o CBT can help you to make sense of CBT can help you to make sense of overwhelming problems by breaking them overwhelming problems by breaking them down into smaller parts. This makes it down into smaller parts. This makes it easier to see how they are connected and easier to see how they are connected and how they affect you.  how they affect you.  

1.1. SituationSituation

2.2. ThoughtsThoughts

3.3. EmotionsEmotions

4.4. Physical feelingsPhysical feelings

5.5. ActionsActions

CBT- OverviewCBT- Overviewo Helps change how you think (‘cognition’) and Helps change how you think (‘cognition’) and

what you do (‘behaviour’)what you do (‘behaviour’)o The cognitive behavioral treatment of BN consists The cognitive behavioral treatment of BN consists

of 20 sessions. of 20 sessions. o The entire process takes about 20 weeks to The entire process takes about 20 weeks to

complete. complete. o Split into Split into three stagesthree stages (Fairburn, 1993) (Fairburn, 1993)

1.1. Cognitive view on the maintenance of bulimia is Cognitive view on the maintenance of bulimia is presented, and behavioral techniques are implemented presented, and behavioral techniques are implemented to replace binge eating with more stable eating to replace binge eating with more stable eating patterns. (8 weeks)patterns. (8 weeks)

2.2. Emphasis placed on the elimination of dieting . Emphasis placed on the elimination of dieting . Cognitive processes are focused upon extensively; the Cognitive processes are focused upon extensively; the therapist and the individual examine his/her thoughts, therapist and the individual examine his/her thoughts, beliefs, and values which maintain the eating problem. beliefs, and values which maintain the eating problem. (8 weeks)(8 weeks)

3.3. focus on developing relapse prevention strategies. (4 focus on developing relapse prevention strategies. (4 weeks)weeks)

CBT- Stage OneCBT- Stage One

1.1. Orient the patient Orient the patient2.2. Establish collaborative Establish collaborative

therapeutic relationshiptherapeutic relationship3.3. Take individual’s history Take individual’s history4.4. Outline rationale Outline rationale5.5. Introduce/review Introduce/review

monitoring sheetsmonitoring sheets

CBT- Stage One con’tCBT- Stage One con’t

6.6. Introduce weekly weighing Introduce weekly weighing7.7. Introduce/review homework Introduce/review homework

assignmentsassignments8.8. Educate about weight/eating Educate about weight/eating9.9. Advice on negative behaviour Advice on negative behaviour

patternspatterns10.10. Joint session with Joint session with

friends/familyfriends/family

CBT- Stage TwoCBT- Stage Two

1.1. continue review/monitor continue review/monitor sheets & homeworksheets & homework

2.2. reduce dieting tendency reduce dieting tendency

3.3. enhance problem solving skills enhance problem solving skills

4.4. address body image concerns address body image concerns

5.5. address other cognitive address other cognitive distortionsdistortions

CBT- Stage ThreeCBT- Stage Three

o Composed of three interviews.Composed of three interviews.o Two week intervals.Two week intervals.o Goal: Maintain progress once Goal: Maintain progress once

treatment is terminated in order to treatment is terminated in order to prevent relapse of the binge/purge prevent relapse of the binge/purge cycle.cycle.

Results- overviewResults- overview

o Review of 16 studiesReview of 16 studieso Based on outcome of CBT-Based on outcome of CBT-

only treatment groupsonly treatment groupso Assessed according to five Assessed according to five

core domains of cognitive core domains of cognitive modelmodel

Results- Low Self EsteemResults- Low Self Esteem

o 5 studies (31%) used as 5 studies (31%) used as outcome variableoutcome variable

o All used Rosenberg Self All used Rosenberg Self Esteem Inventory (1965)Esteem Inventory (1965)

o 3 reported significant 3 reported significant findingsfindings

Results- Distorted Body Results- Distorted Body ImageImage

o 11 (70%) studies evaluated construct 11 (70%) studies evaluated construct in some wayin some way

o Fairburn & CooperFairburn & Coopero Eating Disorders Examination (1993)Eating Disorders Examination (1993)o Body Shape Questionnaire (1987)Body Shape Questionnaire (1987)o Efficacy varies depending on outcome Efficacy varies depending on outcome

measures usedmeasures used

Results- Dietary Results- Dietary ConstraintConstraint

o 2 aspects:2 aspects:1.1. caloric restriction caloric restriction

2.2. cognitive restraint cognitive restrainto 12 (75%) included some form of measure12 (75%) included some form of measureo evidence from mean post-treatment evidence from mean post-treatment

scores on the EDE restraint scale scores on the EDE restraint scale suggests that CBT does reduce restraint suggests that CBT does reduce restraint to normative levels. (Anderson & to normative levels. (Anderson & Maloney, 2001)Maloney, 2001)

Results- BingingResults- Binging

o 13 (81%) used some measure as 13 (81%) used some measure as outcome variableoutcome variable

1.1. food records/self report food records/self report questionnairesquestionnaires

2.2. interviews interviewso Eating Disorders ExaminationEating Disorders Examination

o Combining all methods of assessment, Combining all methods of assessment, CBT reduced binge eating an average CBT reduced binge eating an average of 75% (Anderson & Maloney)of 75% (Anderson & Maloney)

Results- PurgingResults- Purging

o All 16 reported some measureAll 16 reported some measureo Self reportSelf report

o food recordsfood recordso EDEEDE

o CBT reduced compensatory behavior CBT reduced compensatory behavior an average of 78%an average of 78%

Future CBT Outcome Future CBT Outcome Studies (Anderson & Studies (Anderson &

Maloney)Maloney)1.1. Assess all core domains of the cognitive Assess all core domains of the cognitive

model model 2.2. Provide pre- and post-treatment means for Provide pre- and post-treatment means for

critical variables critical variables 3.3. Use the EDE as an outcome measure, but Use the EDE as an outcome measure, but

not as the only outcome measurenot as the only outcome measure4.4. Obtain both objective and subjective Obtain both objective and subjective

measures of binge eating measures of binge eating 5.5. Assess non-purging as well as purging Assess non-purging as well as purging

methods of compensatory behavior methods of compensatory behavior 6.6. Assess dietary restraint using measures of Assess dietary restraint using measures of

both caloric restriction and cognitive both caloric restriction and cognitive restraintrestraint

Other Evidence to Support Other Evidence to Support CBTCBT

o Whittal, Agras, & GouldWhittal, Agras, & Gould (1999) They found that (1999) They found that CBT was associated with substantial improvements CBT was associated with substantial improvements in eating disordered behaviors and eating attitudes. in eating disordered behaviors and eating attitudes. “Improvements with CBT were significantly larger “Improvements with CBT were significantly larger than those for medication in terms of binge than those for medication in terms of binge frequency, purge frequency, and eating attitudes.” frequency, purge frequency, and eating attitudes.”

o Anderson & MaloneyAnderson & Maloney (2001) “Cognitive behavioral (2001) “Cognitive behavioral therapy (CBT) is widely regarded as the treatment of therapy (CBT) is widely regarded as the treatment of choice for bulimia nervosa (BN)”choice for bulimia nervosa (BN)”

o Ricca et. AlRicca et. Al “Compared to any other psychological “Compared to any other psychological or pharmacological treatment for which controlled or pharmacological treatment for which controlled studies have been published, CBT is reported to be studies have been published, CBT is reported to be more effective (the majority of studies), or at least as more effective (the majority of studies), or at least as effective.”effective.”

Advantages Over Other Advantages Over Other MethodsMethods

1.1. No medicationNo medicationo No harmful side effectsNo harmful side effectso No addiction/withdrawalNo addiction/withdrawalo Not just treatment of symptomsNot just treatment of symptoms

2.2. Client involvedClient involvedo Part of goal-making processPart of goal-making processo More likely to have long lasting effectsMore likely to have long lasting effectso Educate on illness (prevention!)Educate on illness (prevention!)

DisadvantagesDisadvantages

1.1. Need specially trained Need specially trained professionalsprofessionals

2.2. Relies heavily on self-report Relies heavily on self-report data (valid?)data (valid?)

3.3. Lengthy treatment/possible Lengthy treatment/possible relapserelapse

4.4. Cost???Cost???

Evaluation of CBTEvaluation of CBT

o Still research need to be done on Still research need to be done on effectivenesseffectiveness

o Excellent alternative to medicationExcellent alternative to medicationo Learning/understanding of problemLearning/understanding of problemo Best available treatmentBest available treatment